Spinal Nerve Roots 335 \PPROXIMATE. REGION OF PERCENTAGE. NERVE MAIN REFLEX SENSORY USUALDISC OF LUMBOSACRAL. RooT WEAKNESS* DECREASED" ABNORMALITY’ INVOLVED RADICULOPATHIES. u Iiopsoas, Patellar tendon. Knee, medial 13a 34-10% quadriceps (knee jerk) Tower leg iB Foot dorsiflexion, None Dorsum of foot, 144s 4or45% big toe extension, big toe foot eversion, si Foot plantar Achilles tendon, Lateral foot, 15-S1 457.-50% flexion {ankle jerk) ‘small toe, sole See Figure 87. See Figure 84. fecal incontinence, and loss of erections. It is essential to detect and treat cauda equina syndrome promptly to avoid irreversible deficits. Cauda equina syndrome can sometimes be difficult to differentiate from conus medullaris syndrome, in which similar deficits occur as the result of a lesion in the sacral segments of the spinal cord (sce Figure 8.1). Causes of cauda equina syndrome include compression by a central disc herniation (see Fig- ure 8.3C), epidural metastases, schwannoma, meningioma, neoplastic meningitis, trauma, epidural abscess, arachnoiditis, and cytomegalovirus polyradiculits. KEY CLINICAL CONCEPT 8.5 COMMON SURGICAL APPROACHES TO THE SPINE Most patients with radiculopathy caused by disc herniation recover within a few months without surgery. Indications for urgent surgery include the rare instances in which cord compression or cauda equina syndrome occurs. Semiurgent surgery is indicated in patients with progressive or severe motor deficits or in the occasional patient with intolerable, medically intractable pain, Elective surgery is contemplated when a clear radiculopathy is present and conservative measures such as rest, physical therapy, and traction have been tried for 1 to3 months but were ineffective In the cervical spine, surgical options include a posterior approach with laminectomy, meaning removal of the lamina over affected levels (see Figure 8.2B), combined with discectomy to remove herniated disc material, and foraminotomy to widen the lateral recess through which the nerve root passes just before it exits the intervertebral foramen. An anterior approach can also be used in the cervical spine. In this procedure, an incision is made in the anterior neck and the dissection is carried down to the vertebral bod- ies. The anterior approach provides direct access to the dises without tra- versing the spinal canal and also allows mechanical fusion of adjacent verte- bral bodies, usually using a bone graft. An anterior approach is also often favored in cases of thoracic disc herniation, which is rare. In the lumbar spine, a posterior approach is generally used. Sometimes a variety of hard- ware is implanted to increase mechanical stability.